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CR373 Late submission / Equity

CR373 Late submission / Equity Claim submitted late as complainant forgot she had covered the deceased; equity considered; decision in favour of the insurer Background 1. The complainant forgot that she had covered her aunt on her employer’s group funeral scheme policy. She was reminded when a consultant visited her office with a printout of […]

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CR352 Equity Insurer relying on two year suicide exclusion clause on replacement policy

CR352 Equity Insurer relying on two year suicide exclusion clause on replacement policy; replaced policies in place with same insurer for 13-21 years; no interruption in cover Background 1. The insured had had continuous life cover with the insurer over a period of 21 years, under three policies commencing in 1990, 1997 and 1998, respectively. […]

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CR343 Equity Disability claim declined; complaint lodged eight years later

CR343 Equity Disability claim declined; complaint lodged eight years later; insurer defending on basis of prescription; whether our office could come to complainant’s assistance on grounds of equity. Background 1. The complainant, a member of the SAPS, submitted a claim on 29 January 2002 for the disability cash benefit (R30 000) on his universal policy. […]

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CR336 Equity Funeral benefit claim rejected on grounds of late submission

CR336 Equity Funeral benefit claim rejected on grounds of late submission – equity – over much of this period at issue policyholder hospitalised and receiving medical attention. Background Mrs G had a funeral benefit policy containing a provision that any claim must be made within 12 months of the date of death of the deceased […]

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CR307 Equity – Group scheme

Equity CR307 Group scheme – claim under group disability scheme repudiated on grounds of late submission – late submission policy provision in principle enforceable, unless considerations of equity demand otherwise – equity ruling not fair to insurer in the particular circumstances. Background 1. The complainant, a general labourer, worked for a construction company. He was […]

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CR305 Equity – Definition in relevant clause out of date

Equity CR305 Definition in relevant clause out of date – strict application of it unfair and wasteful – application of equity – insurer’s obligation to obtain necessary medical evidence. Agtergrond Vanweë pyn in haar borskas en palpitasies het Mev A haar dokter vanaf 12 Julie 2009 tot 9 November 2009 driemaal gekonsulteer. Hy het haar […]

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CR286 Late submission of claims [Cross reference from Interpretation; Disability; Equity]

CR286 Late submission of claims [Cross reference from Interpretation; Disability; Equity] Disability claim rejected on grounds of late submission – interpretation of contract – how to determine date of disability – claim subsequently repudiated on grounds that claimant no longer a member of scheme at date of disability – application of equity Background 1. The […]

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CR278 EQUITY (Cross reference from “Group schemes”)

CR278 EQUITY (Cross reference from “Group schemes”) Failure to apply for paid-up policy upon retirement – insured unaware of the policy provision that he should make such application. Background A labour union had arranged for a group funeral scheme, and the policyholder later became a member of the scheme. The policy required that, if a […]

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CR242 Equity Exception in policy covering disability

CR242 Equity Exception in policy covering disability – clause excluding intentionally or self induced illness or injury – insured donated one of her kidneys to save life of her brother – role of equity Background The complainant had one of her kidneys transplanted to her brother in order to save his life. For this purpose […]

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CR84 Funeral policy

CR84 Funeral policy – claim repudiated on basis that deceased did not fall within definition of “spouse” and complainant did not pay funeral costs – “common law spouse” – equity. Background The complainant took out a funeral policy in 2001. He elected to pay premiums for “member, spouse and children” to include cover for the […]

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